COVID-19 has managed to transcend national, cultural, linguistic, political, moral, and class boundaries. But, while the disease affects us all, some people are predisposed to be hit harder, making an inconvenience for some a calamity for others. In the United States, barriers to quality healthcare have long existed for people of color and low socioeconomic means, and the pandemic has only heightened these gross inequalities. The phrase “We’re all in this together,” which we heard thousands of times in the early moments of the pandemic, quickly lost its luster to Americans whose needs were not met by the healthcare system. Such wide disparities in the quality of healthcare accessible to different communities are inexcusable. The disproportionate burden of COVID-19 on disadvantaged communities illustrates the immense need to improve healthcare for these communities. It is essential that we invest time, work, and money to ensure our healthcare system can provide high-quality care to all Americans, regardless of the area they live in, the hours they work, the language they speak, race, or socioeconomic means. 

I sat down with Dr. Geetanjali Srivastava, a pediatric emergency medicine physician who is the medical director of Valley Children’s Hospital in Fresno, California and has a Master’s degree in Public Health with a focus on healthcare policy, to discuss the inequalities she dealt with in the emergency department during the COVID-19 pandemic and her vision of how to build a stronger and more equitable healthcare system for Americans. The patient situations that Dr. Geetanjali describes illustrate that American healthcare inequalities are intricately connected to larger social issues; therefore, they cannot be solved in isolation. To address these inequalities, not only does the healthcare system need to be reformed, the institutions that cause entire communities to be disadvantaged need reform. 

Author’s Note: This interview was edited for clarity. 

Niraj: Does lack of insurance deter people from receiving primary care? Is it common for people to come to the emergency department with severe conditions that could have been prevented if they saw a primary care physician earlier?

Dr. Geetanjali: I think American citizens know to bring their child to the emergency department when they are sick, and they know that we are going to take care of them. That’s why I love being in emergency medicine—I never have to say “No” to anybody. I think if you have no health insurance and no primary care physician, then people access healthcare through the ER. If someone doesn’t have health insurance, there is a risk that they will come to the ER too late where something minor has progressed into a much more significant illness or injury, but it happens less often than you would think. 

For people of lower socioeconomic means who don’t primarily speak English and are not in the United States legally, I think they are very scared to bring their children to the ER because they think they might be arrested due to what was going on under the last administration. People were never arrested or deported from the ER, but fear keeps people away. I think it deterred people from seeking all kinds of social services. If you hear on national television that you’re not wanted, that you’re illegal, and that ICE is arresting parents in front of their kids at school—which they were doing in California—do you think they are going to the ER where there are security guards that take your phone number, insurance, and other demographic information? Unless their child is really sick, they’re not going to come to the ER. So for people that don’t speak English as their primary language and aren’t here legally, I absolutely think they come to the ER very late; but for an American citizen, fortunately, most people will come at a pretty good time and not be too delayed.

Niraj: What are some of the major inequalities you see in healthcare?

Dr. Geetanjali: I don’t think the healthcare disparities were shocking to people in healthcare. We see it on a daily basis, honestly. I do think it shows that our healthcare system is heavily reliant on emergency medicine, meaning we don’t have really good primary care services. They are very hard to access, so people choose to engage in healthcare through the emergency department. I think we’ve always known that because we’re there twenty-four seven. I think that our healthcare system needs to be available to families sixteen hours a day. People that work eight to five can’t go to the doctor if their kid’s sick. When they need healthcare, where do they go? They go to the ER. So we need to do something so that parents and kids that have a full day of school and work can access primary care without having to take a day off. And most people don’t get paid for time off for doctor’s appointments. They work part-time and don’t have health insurance or have days they can take off but have no paid time off; every day they don’t work, they don’t get money. That shows not just a healthcare disparity but a social disparity.

Niraj: In the area your hospital serves, what are groups of people who are at a disadvantage for receiving healthcare?

Dr. Geetanjali: We see a lot of people in the middle of the night whose parents literally work all day long picking vegetables and fruit. They’re coming to the ER at two in the morning, ten at night, midnight for minor things sometimes, but where else are they going to take their kids? They get up at four or five in the morning, someone takes their kids to school, and they don’t get home until six or seven in the evening. My team at the emergency department gives good healthcare, and we really try to do the best we can; but is it the best place to get healthcare for your kids? Probably not. There’s no continuity; it’s acute care. 

I think we need better access for people that don’t have your typical eight-to-five life and don’t have all the benefits that a lot of us do, like paid time off and health insurance. I see this all the time. A lot of the kids’ parents don’t have benefits because the company they work for makes sure that they don’t work full-time. For example, if full-time work is considered thirty-eight hours, they’ll give them thirty-five hours of work, so they don’t have to pay their healthcare benefits. They don’t get any sick leave or vacation leave, so they can fire you. If you take two days off of work because your kid’s sick, they can literally fire you, so parents are really scared. It’s really hard because for every day that they don’t work, it’s a job that they can lose and it’s food that’s not on the table. 

It’s not an easy issue. Everything is gray. You can’t say, “Of course you have to be with your child, and you’re a bad parent if you can’t.” You have to realize that if they stay with their kids, there can be severe consequences for them. It’s very complicated because every decision has consequences. It’s not black and white. I think physicians have to look at the whole picture and be less judgmental. Physicians need to work with the family and their needs. I meet in the middle with families. I try to come up with solutions so that the parents can still work, but their kid’s still taken care of. But you have to work that out. 

Niraj: Medicine isn’t always medicine.

Dr. Geetanjali: And it shouldn’t be. You absolutely have to look at the person as a whole and the family as a whole.

Niraj: What are some issues that people of lower socioeconomic means encounter with COVID-19?

Dr. Geetanjali: People of lower socioeconomic means are still working in the grocery store, working in the farms, picking vegetables, and meatpacking. We saw that a lot of our lower socioeconomic group, people who didn’t have options to work at home, were exposed to COVID-19. A lot of times they weren’t separated enough from each other, so they had a high rate of positivity, even in Amazon distribution centers. Some of that is negligence on the owner’s part for not having good protocols for their workers. People who are of lower socioeconomic means are usually not English-speaking, not as well-educated, and people of color, and statistically, they were the people most affected by COVID-19 because they still had to work in-person even when other people were at home.

Niraj: If someone tested positive, what would you do when they had to work?

Dr. Geetanjali: Tell them to quarantine. It was really hard. I remember I had one family where the wife’s husband owned a grocery store, and I said, “I think I need to test your daughter.” And she would not let me test because she knew if the girl tested positive, the whole family would have to quarantine. And she was mad, and I totally understood it. If the husband didn’t work in the grocery store, they wouldn’t eat. So what do you do? You can’t force people to get tested. You can definitely encourage it. But I totally saw her point of view. It’s hard. I said to her, “Well, your husband could infect other people. We should find out,” but she was pretty adamant that we not test her daughter because then the city would know. COVID was and still is reportable to the state. She knew that we could report positivity to the state and that her husband would have to quarantine if he tested positive. 

Niraj: Can you think of any ways to fix that?

Dr. Geetanjali: I think that’s where you talk about Scandinavian countries where they have a really good safety-net, which let them protect people through COVID-19. Our government did have COVID-pay. My physicians had something called COVID-pay. If they tested positive, we were going to support the family for fourteen days of income.

Niraj: But that’s not a legal responsibility of the company?

Dr. Geetanjali: No, it’s not. But we chose to do that as a company. And the government definitely supported COVID-pay. Though you have to be legal to receive it, I think. For example, migrant workers illegally in the United States probably couldn’t get COVID-pay. If you’re a legal migrant worker, you could have qualified, but the process of applying is difficult. Companies would apply to the government for COVID-pay, which they would pass on to their sick workers. It incentivized the company to report positivity, and the government reimbursed the company whatever they paid the sick worker, which I think is a good way of doing it. But they only did that for so long. At some point, this policy expired, which makes sense because we can’t endlessly pay for that. Definitely during the really hard parts of the pandemic, COVID-pay helped out.

Niraj: Are you taught about how to deal with these inequalities in training as a doctor and for your MPH?

Dr. Geetanjali: I think you are now. Definitely not when I was training twenty-five years ago. They definitely are more cognizant of things like cultural diversity and gender—all the things that you now learn in school, they are teaching in medical school, which I think is great. Luckily, I have a personal interest in this topic which is why I studied public health. I have an interest in serving underserved communities. I’ve always worked in lower-socioeconomic, inner-city hospitals—that is my life’s work—and I will continue to do that. It’s always been my passion—what drives me in medicine. But, we can always do better and train people, and I think that’s finally happening. Do I think it’s enough? Probably not. But at least it’s much better than when I was training.

Niraj: What qualities do you think future healthcare professionals should have as opposed to people in the past?

Dr. Geetanjali: I think people need to come from a liberal arts background. I think learning about non-science subjects during undergrad is really important. Think: economics, social studies, psychology, how the mind works, how people work, and having more empathy. These things are really important in medicine. Talking about wellness, your sleep, and taking care of your own self—your own body and mind—is also extremely important. 

You should not just be the doctor telling someone what to do but be much more of an ally to your patients and their families. Be someone that understands how people make decisions and how to meet them where they are, regardless of their socioeconomic means, race, language, and culture. Building that education is essential. I don’t know how to do it, but it should be better than what I learned.